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Application for Professional ID Card

The document is an application for a Professional Identification Card (PIC) for Michelle Perez Arbonida, a Filipino nurse with a license number of 0435734. It includes personal details, appointment information, and a declaration of consent for data collection and accuracy of provided information. Additionally, it outlines requirements for continuing professional development (CPD) units for PIC renewal and instructions for representatives applying on behalf of professionals.

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Rea Danica Tingson
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8 views1 page

Application for Professional ID Card

The document is an application for a Professional Identification Card (PIC) for Michelle Perez Arbonida, a Filipino nurse with a license number of 0435734. It includes personal details, appointment information, and a declaration of consent for data collection and accuracy of provided information. Additionally, it outlines requirements for continuing professional development (CPD) units for PIC renewal and instructions for representatives applying on behalf of professionals.

Uploaded by

Rea Danica Tingson
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

TIME RECEIVED:

TIME RELEASED:

Professional Regulation Commission

APPLICATION FOR PROFESSIONAL IDENTIFICATION CARD (PIC)

NOT FOR SALE (REPRODUCTION IS ALLOWED)

APPOINTMENT DATE: December 23, 2021 (11:00 AM TO 12:00 PM) - PRC Zamboanga
REFERENCE NO: RE2LNHQEOLY0 | OR: 133622450888 | Amount: PHP 450.00
NAME: ARBONIDA, MICHELLE PEREZ

CITIZENSHIP: FILIPINO BIRTHDATE: April 08, 1986

PERMANENT MAILING ADDRESS: 186 RIVERSIDE SAN ROQUE ZAMBOANGA CITY, ZAMBOANGA DEL SUR
TEL. NO. / CP NO.: +966508415966 EMAIL ADDRESS: arbonida_michelle@[Link]
SCHOOL GRADUATED: WESTERN MINDANAO STATE U-ZAMBOANGA CITY DATE GRADUATED: March 27, 2007
REGISTRATION DATE: October 18, 2007 EXPIRATION DATE: April 08, 2025
PROFESSION: NURSE LICENSE NO.: 0435734

DECLARATION AND ATTESTATION

I am aware and I give my consent to the collection of the data required by this application form and
the taking of my photograph, and if applicable, the taking of my fingerprints.

I further attest that all particulars and supporting documents provided by me are correct and
complete. I am aware that any false statement or fraudulent document will lead to the rejection of my
application or to the cancellation of my PIC already issued, and may also render me liable under applicable
administrative and criminal laws.

SIGNATURE OF LICENSEE

UNDERTAKING

(To be filled up by professionals, except for Real Estate Practitioners, who failed to comply with the
required CPD Credit Units for the renewal of Professional Identification Card)

For this compliance period, I am submitting CPD units of the total required CPD Credit units. I
hereby undertake to submit the balance of CPD credit units in addition to the required CPD units (or a
total of units) for the next renewal of my PIC. I understand that in the event I fail to comply, my PIC will
not be renewed.

SIGNATURE OF LICENSEE

NOTE:
1) ALL REAL ESTATE PRACTITIONERS CANNOT AVAIL THE UNDERTAKING AND HAVE TO
PROVIDE PROOF OF COMPLIANCE WITH CPD PRIOR TO RENEWAL OF PIC PURSUANT TO
SECTION 17, ARTICLE III OF REPUBLIC ACT NO. 9646 OR THE REAL ESTATE SERVICE ACT
OF THE PHILIPPINES AND BOARD RESOLUTION NO. 49, S. 2015.
2) REPRESENTATIVE OF THE PROFESSIONAL APPLYING FOR ISSUANCE OF PROFESSIONAL
IDENTIFICATION CARD (PIC) MUST SUBMIT:
a) THE PRESCRIBED AUTHORIZATION LETTER AND PHOTOCOPY OF PROFESSIONAL
IDENTIFICATION CARD (PIC) OF THE REPRESENTATIVE AND EXPIRED PIC OF THE
PRFESSIONAL; OR
b) SPECIAL POWER OF ATTORNEY (SPA) AND PHOTOCOPY OF ANY VALID GOVERNMENT
ISSUED IDENTIFICATION CARD (ID) OF THE REPRESENTATIVE AND THE PROFESSIONAL
3) STRICTLY FOLLOW THE APPOINTMENT DATE ON RENEWAL OF PROFESSIONAL
IDENTIFICATION CARD (PIC).

REG-03
Rev. 02
September 15, 2017
Page 1 of 1

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